=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134684913
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GIGI KORATTIKARA PHILIP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/05/2019
-----------------------------------------------------
Last Update Date | 02/05/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4500 S LANCASTER RD
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75216-7167
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-857-1624
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 606 HARVEST HILL DR
-----------------------------------------------------
City | MURPHY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75094-4196
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-232-7627
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | AP140248
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------